Concise Book of Trigger Points

RHOMBOIDEUS (MINOR AND MAJOR) Greek, rhomb, a parallelogram with oblique angles and only the opposite sides equal; minor, small; major, large. So named because of its shape. Origin Spinous processes of the seventh cervical vertebra and upper five thoracic vertebrae (C7-T1). Insertion Medial (vertebral) border of scapula. Action Retracts (adducts) scapula. Stabilizes scapula. Slightly assists in outer range of adduction of arm (i.e. from arm overhead to arm at shoulder level). Nerve Dorsal scapular nerve, C4, 5. Basic functional movement Example: Pulling something towards you, such as opening a drawer. Indications Localized pain or chronic aching (C7-T5) region - medial or peri-scapular. Scapulothoracic joint grinding/grating or crunching. Referred pain patterns Medial border of scapula, wrapping around superior aspect of spine of scapula towards the acromion process. Differential diagnosis Scapulocostal syndrome. Fibromyalgia. Also consider Levator scapulae. Middle trapezius. Infraspinatus. Scalenes. Latissimus dorsi. Advice to patient Posture. Tight pectoralis muscles. 'Round shoulders'. Occupational posture. Techniques Spray and stretch Dry needling Injections Trigger point release (N.B. pleural cavity)

SERRATUS ANTERIOR

SERRATUS ANTERIOR Latin, serratus, serrated; anterior, before. The serratus anterior forms the medial wall of the axilla, along with the upper five ribs. It is a large muscle composed of a series of finger-like slips. The lower slips interdigitate with the origin of the external oblique. Origin Outer surfaces and superior borders of upper eight or nine ribs and the fascia covering their intercostal spaces. Insertion Anterior (costal) surface of the medial border of scapula and inferior angle of scapula. Action Rotates scapula for abduction and flexion of arm. Protracts scapula (pulls it forward on the chest wall and holds it closely to the chest wall), facilitating pushing movements such as push-ups or punching. Nerve Long thoracic nerve, C5, 6, 7, 8. Note: A lesion of the long thoracic nerve will result in the medial border of the scapula falling away from the posterior chest wall, resulting in a 'winged scapula' (looking like an angel's wing). A weak muscle will also produce a winged scapula, especially when holding a weight in front of the body. Basic functional movement Example: Reaching forwards for something barely within reach. Indications Chest pain which does not abate with rest. Breast pain and sensitivity. Panic attacks. Dyspnoea. Chronic cough. Asthma. Renal tubular acidosis. Scapula winging. Chronic 'stitch' on running. Stress. Referred pain patterns Local: where each digitation attaches to rib. Central: rib (6-8), localized pain radiating anterior and posterior in a 5-10cm patch. Pain inferior angle of scapula. Pain in ulnar aspect of the upper extremity. Differential diagnosis T7/T8 intercostal nerve entrapment. Herpes zoster. Local vertebral alignment. Rib lesions. Breast pathologies. Reflex-sympathetic dystrophy. Also consider Pectoralis major. Sternocleidomastoideus. Scalenus medius. Trapezius. Rhomboideus. Diaphragm. External oblique. Advice to patient Avoid cars with heavy steering. Take care with weight-training, especially push-ups and bench press. Avoid stress. Try meditation/relaxation. Techniques Spray and stretch Dry needling Injections Trigger point release

PECTORALIS MAJOR

PECTORALIS MAJOR Latin, pectoral is, chest; major, large. Along with pectoralis minor, pectoralis major forms the anterior wall of the axilla. Origin Clavicular head: medial half or two thirds of front of clavicle. Sternocostal portion: front of manubrium and body of sternum. Upper six costal cartilages. Rectus sheath. Insertion Crest below greater tubercle of humerus. Lateral lip of intertubercular sulcus (bicipital groove) of humerus. Action Adducts and medially rotates the humerus. Clavicular portion: flexes and medially rotates the shoulder joint, and horizontally adducts the humerus towards the opposite shoulder. Sternocostal portion: obliquely adducts the humerus towards the opposite hip. The pectoralis major is one of the main climbing muscles, pulling the body up to the fixed arm. Nerve Nerve to upper fibres: lateral pectoral nerve, C5, 6, 7. Nerve to lower fibres: lateral and medial pectoral nerves, C6, 7, 8, T1. Basic functional movement Clavicular portion: brings arm forwards and across the body, e.g. as in applying deodorant to opposite armpit. Sternocostal portion: pulling something down from above, e.g. such as a rope in bell ringing. Indications Post myocardial infarct rehabilitation. Cardiac arrhythmia. Mid-scapular back pain. Breast pain and hypersensitivity. Thoracic outlet syndrome. Anterior shoulder pain. Golfer's and tennis elbow. Referred pain patterns Clavicular portion: local pain radiating to the anterior deltoid and long head of biceps brachii area. Sternal portion: 'acute' back pain into anterior chest wall in a 10-20cm patch of diffuse pain around the medial border of the upper extremity. Stronger pain below medial epicondyle in a 5cm patch, diffuse pain into the 4th and 5th digits. Costal portion: 5-6th ribs leads to severe cardiac referral (even at night). Intense breast pain (10-15cm patch). Diffuse radiations into axillary tail, and into axilla. Differential diagnosis C5-C6 radiculopathy. Biceps tendonitis. Rotator cuff muscle lesions. Intrathoracic pathology. Oesophageal pathology. Tietze's syndrome. Ischaemic heart disease (angina). Thoracic outlet syndrome. Also consider Latissimus dorsi. Subscapularis. Teres minor. Infraspinatus. Trapezius (middle fibres). Serratus anterior. Advice to patient Round shouldered posture leads to shortening. Work sitting posture is key. Sleeping posture, especially hands folded over chest or hands above head. Bra type and support may be relevant. Techniques Spray and stretch Dry needling Injections Trigger point release

LATISSIMUS DORSI

LATISSIMUS DORSI Latin, latissimus, widest; dorsi, of the back. Along with subscapularis and teres major, the latissimus dorsi forms the posterior wall of the axilla. Origin Thoracolumbar fascia, which is attached to the spinous processes of lower six thoracic vertebrae and all the lumbar and sacral vertebrae, (T7-S5) and to the intervening supraspinous ligaments. Posterior part of iliac crest. Lower three or four ribs. Inferior angle of the scapula. Insertion Floor of the intertubercular sulcus (bicipital groove) of humerus. Action Extends the flexed arm. Adducts and medially rotates the humerus. It is one of the chief climbing muscles, since it pulls the shoulders downwards and backwards, and pulls the trunk up to the fixed arms (therefore, also active in crawl swimming stroke). Assists in forced inspiration by raising the lower ribs. Nerve Thoracodorsal nerve, C6, 7, 8, from the posterior cord of the brachial plexus. Basic functional movement Example: Pushing on arms of chair to stand up. Indications 'Thoracic' back pain; constant in nature and unrelated to activity. Referred pain patterns Axillary trigger point: a 5-10cm zone of pain at the inferior angle of scapula with diffuse pain radiating into the medial upper extremity into ulnar aspect of hand. Lower lateral trigger point: triangular pattern from trigger point into the brim of pelvis and regimental badge area. Differential diagnosis C7 neuropathy. Ulnar neuropathy. Subscapular nerve entrapment. Axillary neuropathy. Thoracic outlet syndrome. Cardiopulmonary diseases. Also consider Rhomboideus. Trapezius (middle fibres). Teres major. Scalenes. Subscapularis. Iliocostalis. Serratus anterior. Advice to patient Avoid overloading, e.g. pulling objects down from above head. Techniques Spray and stretch Dry needling Injections Trigger point release

DELTOIDEUS



SUPRASPINATUS



INFRASPINATUS

INFRASPINATUS Latin, infra, below; spina, spine. A member of the rotator cuff, which comprise: supraspinatus, infraspinatus, teres minor and subscapularis. The rotator cuff helps hold the head of the humerus in contact with the glenoid cavity (fossa, socket) of the scapula during movements of the shoulder, thus helping to prevent dislocation of the joint. Origin Infraspinous fossa of the scapula. Insertion Middle facet on the greater tubercle of humerus. Capsule of shoulder joint. Action As a rotator cuff, helps prevent posterior dislocation of the shoulder joint. Laterally rotates humerus. Nerve Suprascapular nerve, C(4), 5, 6, from the upper trunk of the brachial plexus. Basic functional movement Example: Brushing back of hair. Indications Decreased range of motion in the Apley's scratch test (behind back). Hemiplegia. Rotator cuff tendinopathy. Frozen shoulder syndrome. Referred pain patterns Middle/upper cervical spine: deep anterior shoulder joint zone of 3-4cm in region of long head of biceps brachii radiating into biceps belly, then into forearm - diffuse symptoms in median nerve distribution. Medial/scapula: to medial border of scapula. Differential diagnosis Biceps tendonitis. C5-C6 neuropathy. Suprascapular nerve dysfunction. Also consider Infraspinatus. Subscapularis. Levator scapulae. Pectoralis minor /major. Long head of biceps brachii. Biceps brachii. Anterior deltoideus. Teres major. Latissimus dorsi. Advice to patient Avoid reaching into back seat of car. Heat can be beneficial. Support arm on pillow for relief. Techniques Spray and stretch Dry needling Injections Trigger point release

TERES MINOR

TERES MINOR Latin, teres, rounded; finely shaped; minor, small. A member of the rotator cuff, which comprise: supraspinatus, infraspinatus, teres minor and subscapularis. The rotator cuff helps hold the head of the humerus in contact with the glenoid cavity (fossa, socket) of the scapula during movements of the shoulder, thus helping to prevent dislocation of the joint. Origin Upper two-thirds of the lateral border of the dorsal surface of scapula. Insertion Lower facet on the greater tubercle of humerus. Capsule of shoulder joint. Action As a rotator cuff, helps prevent upward dislocation of the shoulder joint. Laterally rotates humerus. Weakly adducts humerus. Nerve Axillary nerve, C5, 6, from the posterior cord of the brachial plexus. Basic functional movement Example: Brushing back of hair. Indications Shoulder pain; especially posterior. Frozen shoulder syndrome. Rotator cuff rehabilitation. Subacromial bursitis. Biceps tendonitis. Referred pain patterns Localized zone (2-5cm) of intense pain in regimental badge area, with a more diffuse elliptical zone of pain spreading in the postero-lateral upper extremity (above the elbow). Differential diagnosis C8-T1 radiculopathy. Rotator cuff tendinopathy. Shoulder-wrist-hand syndrome. Subacromial/deltoid bursitis. Shoulder impingement syndromes (painful arc). Acromioclavicular joint dysfunction. Also consider Infraspinatus. Advice to patient Posture (round shouldered). Arm position during sleep. Avoid overload. Self stretch. Techniques Spray and stretch Dry needling Injections Trigger point release

SUBSCAPULARIS

SUBSCAPULARIS Latin, sub, under; scapular, pertaining to the scapula. A member of the rotator cuff, which comprise: supraspinatus, infraspinatus, teres minor and subscapularis. The rotator cuff helps hold the head of the humerus in contact with the glenoid cavity (fossa, socket) of the scapula during movements of the shoulder, thus helping to prevent dislocation of the joint. The subscapularis constitutes the greater part of the posterior wall of the axilla. Origin Subscapular fossa and the groove along the lateral border of the anterior surface of scapula. Insertion Lesser tubercle of humerus. Capsule of shoulder joint. Action As a rotator cuff, stabilizes glenohumeral joint, mainly preventing the head of the humerus being pulled upwards by the deltoideus, biceps and long head of triceps. Medially rotates humerus. Nerve Upper and lower subscapular nerves, C5, 6, 7, from the posterior cord of the brachial plexus. Basic functional movement Example: Reaching into your back pocket. Indications Rotator cuff tendinopathy, adhesive capsulitis (frozen shoulder) decreased. Abduction, decreased external rotation. Referred pain patterns Axillary trigger point: strong zone (5-8cm) of pain in posterior glenohumeral joint, with a peripheral diffuse zone. Also radiating down posterior aspect of arm and antero-posterior carpals of wrist. Differential diagnosis Impingement syndromes. Rotator cuff dysfunctions. Thoracic outlet syndromes. Cervical radiculopathy (C7). Cardiopulmonary pathology. Also consider Infraspinatus. Pectoralis minor. Advice to patient Round shouldered postures. Walking posture. Techniques Spray and stretch Dry needling Injections Trigger point release

TERES MAJOR

TERES MAJOR Latin, teres, rounded, finely shaped; major, large. The teres major, along with the tendon of latissimus dorsi, which passes around it, and the subscapularis, forms the posterior fold of the axilla. Origin Oval area on the lower third of the posterior surface of the lateral border of the scapula. Insertion Medial lip of the intertubercular sulcus (bicipital groove) of humerus. Action Adducts humerus. Medially rotates humerus. Extends humerus from the flexed position. Nerve Lower subscapular nerve, C5, 6, 7, from the posterior cord of the brachial plexus. Basic functional movement Example: Reaching into your back pocket. Indications Frozen shoulder syndrome. Pain on reaching above the head. Slight pain on rest. Pain when driving. Impingement syndromes. Referred pain patterns Deep pain into posterior glenohumeral joint and an oval zone (5-10cm) of pain in posterior deltoid area (can radiate strongly to long head of biceps brachii). Diffuse pain into dorsum of forearm. Differential diagnosis Impingement syndromes. Rotator cuff tendinopathy. Cervical neuropatterns (C6-C7). Thoracic outlet syndrome. Supraspinatus calcification. Also consider Rhomboideus. Long head of triceps brachii. Latissimus dorsi. Teres minor. Pectoralis minor. Posterior deltoideus. Advice to patient Use heat/warmth, especially hot showers. Avoid heavy steering (wheels). Monitor gym activities. Use a pillow at night (to hug). Plenty of self stretching. Techniques Spray and stretch Dry needling Injections Trigger point release

BICEPS BRACHII

BICEPS BRACHII Latin, biceps, two-headed muscle; brachii, of the arm. Biceps brachii operates over three joints. It has two tendinous heads at its origin and two tendinous insertions. Occasionally it has a third head, originating at the insertion of coracobrachialis. The short head forms part of the lateral wall of the axilla, along with coracobrachialis and the humerus. Origin Short head: tip of corocoid process of scapula. Long head: supraglenoid tubercle of scapula. Insertion Posterior part of radial tuberosity. Bicipital aponeurosis, which leads into the deep fascia on medial aspect of forearm. Action Flexes elbow joint. Supinates forearm. (It has been described as the muscle that puts in the corkscrew and pulls out the cork.) Weakly flexes arm at the shoulder joint. Nerve Musculocutaneous nerve, C5, 6. Basic functional movement Examples: Picking up an object. Bringing food to mouth. Indications Anterior shoulder pain with decreased arm extension. Biceps tendonitis. Reduced extension of arms. Reduced Apley's scratch test manoeuvre. Frozen shoulder syndrome. Referred pain patterns Localized pain with intense ellipse superficially located over the long head tendon. Referred pain into anterior cubital fossa. Differential diagnosis Gleno-humeral osteoarthritis. Acromioclavicular osteoarthritis. Supscapularis. Infraspinatus. Subacromial bursitis. Biceps tendonitis. C5 radiculopathy. Also consider Subscapularis. Infraspinatus. Brachialis. Supinator. Upper trapezius. Coracobrachialis. Triceps brachii. Advice to patient Exercise antagonists (triceps brachii). Reduce load on biceps brachii when carrying with a bent arm. Sleeping position. Work posture. Techniques Spray and stretch Dry needling Injections Trigger point release

TRICEPS BRACHII

TRICEPS BRACHII Latin, triceps, three-headed muscle; brachii, of the arm. The triceps originates from three heads and is the only muscle on the back of the arm. Origin Long head: infraglenoid tubercle of the scapula. Lateral head: upper half of posterior surface of shaft of humerus (above and lateral to the radial groove). Medial head: lower half of posterior surface of shaft of humerus (below and medial to the radial groove). Insertion Posterior part of the olecranon process of the ulna. Action Extends (straightens) elbow joint. Long head can adduct the humerus and extend it from the flexed position. Stabilizes shoulder joint. Nerve Radial nerve, C6, 7, 8, T1. Basic functional movement Examples: Throwing objects. Pushing a door shut. Indications Golfer's elbow. Tennis elbow. Arthritis of elbow and/or shoulder. Chronic use of crutches/walking stick. Repetitive mechanical activities of arms. Raquet sports. Referred pain patterns a) Long head: pain at supero-lateral border of shoulder radiating diffusely down posterior upper extremity with a strong zone of pain around olecranon process, and then vaguely into the posterior forearm; b) medial head: 5cm patch of pain in medial epicondyle radiating along medial border of forearm to digits 4 and 5; c) lateral head: strong midline pain into upper extremity radiating vaguely into posterior forearm. Differential diagnosis Radial nerve injury. Ulnar neuropathy. C7 neuropathy (cervical disc). Also consider Teres minor. Teres major. Latissimus dorsi. Anconeus. Supinator. Brachioradialis. Extensor carpi radialis Iongus. Advice to patient Review arm positions on repetitive manual work. Take regular breaks. New tennis raquet or widen grip. Avoid overhead activities. Techniques Spray and stretch Dry needling Injections Trigger point release



PRONATOR TERES

PRONATOR TERES Latin, pronate, bent forward; teres, rounded, finely shaped. Origin Humeral head: lower third of medial supracondylar ridge and the common flexor origin on the anterior aspect of the medial epicondyle of humerus. Ulnar head: medial border of the coronoid process of the ulna. Insertion Mid-lateral surface of radius (pronator tuberosity). Action Pronates forearm. Assists flexion of elbow joint. Nerve Median nerve, C6, 7. Basic functional movement Examples: Pouring liquid from a container. Turning a doorknob. Indications Pain in wrist (lateral). Pain on supination. Hairdressers (overuse of scissors). Inability to 'cup' hands together, esp. 'cupping' and extension of the wrist. Shoulder pain (compensatory). Wrist pain on driving. Referred pain patterns Strong pain 'deep' into palmar region of the wrist (lateral), radiating up the antero-lateral forearm. Differential diagnosis De Quervain's tenosynovitis. Carpal tunnel swelling. Osteoarthritis of proximal thumb joint. Distal radio-ulnar discopathy. Epicondylitis. Also consider Finger flexors. Scalenes. Pectoralis major. Advice to patient Stretching techniques. Self massage. Change grip and techniques in tennis/golf. Review driving posture Tanedchgnriiqpuoens steering wheel. Spray and stretch Dry needling Injections Trigger point release

PALMARIS LONGUS

PALMARIS LONGUS Latin, palmaris, palma, palm; longus, long. Part of the superficial layer, which also includes: pronator teres, flexor carpi radialis and flexor carpi ulnaris. The palmaris longus muscle is absent in 13% of the population. Origin Common flexor origin on the anterior aspect of the medial epicondyle of humerus. Insertion Superficial (front) surface of flexor retinaculum and apex of the palmar aponeurosis. Action Flexes the wrist. Tenses the palmar fascia. Nerve Median nerve, C(6), 7, 8, T l . Basic functional movement Examples: Grasping a small ball. Cupping the palm to drink from the hand. Referred pain patterns DInidffiucsaetipoanisn in anterior forearm; intense pain zone 2-3cm in palm of hand surrounded by a superficial Pzoanine aonfdpr'sicokrelinnegssa'nidn npeaelmdleo-flihkaensde.nTsaetnidoenrsn. ess in hand/palm. Functional loss of power in grip. Tennis elbow. Differential diagnosis Neurogenic pain. Dupuytren's contracture. Carpal tunnel syndrome. Complex regional pain syndrome (reflex sympathetic dystrophy). Scleroderma. Dermatomyositis. Also consider Flexor carpi radialis. Brachialis. Pronator teres. Wrist joints (carpals). Triceps brachii. Advice to patient Avoid prolonged 'gripping', especially of power tools or during massage therapy. Stretching and heat. Regular breaks. Techniques Spray and stretch Dry needling Injections Trigger point release

WRIST FLEXORS

WRIST FLEXORS Latin, flex, to bend; carpi, of the wrist; radius, staff, spoke of wheel; ulnaris, of the elbow/arm; digit, finger; superficialis, on the surface; profundus, deep. Flexor carpi radialis, flexor carpi ulnaris, flexor digitorum superficialis and flexor digitorum profundus. Origin Common flexor origin on the anterior aspect of the medial epicondyle of humerus (i.e. lower medial end of humerus). Insertion Carpals, metacarpals and phalanges. Action Flex the wrist joint. (Flexor carpi radialis also abducts the wrist; flexor carpi ulnaris also adducts the wrist). Nerve Median nerve, C6, 7, 8, T l . Basic functional movement EInxdaimcaptlieosn: sPulling rope in towards you. Wielding an axe or hammer. Pouring liquid from bottle. Turning Hdoaonrd,hawnrdislet .and finger pain. Trigger finger. Cutting with scissors. Gripping. Golfer's elbow. Repetitive strain injury. Hairdressers. Turning hand to cupping action. Tense finger flexors. Referred pain patterns Individual muscles refer to the lower arm, wrist, hand, and fingers (see diagrams). Differential diagnosis Ulnar neuritis. Cervical neuropathies. Carpal bone dysfunctions. De Quervain's tenosynovitis. Repetitive strain injury. Osteo- and rheumatoid arthritis. Radio-ulnar disc (distal) problems. Carpal tunnel syndrome. Medial epicondylitis. Also consider Shoulder muscles. Upper arm muscles. Scalenes. Flexor pollicis longus. Advice to patient Avoid prolonged gripping. Avoid repeated twisting (screwdriver). Change golf grip. Take regular breaks. Regular finger stretching. Techniques Spray and stretch Dry needling Injections Trigger point release

BRACHIORADIALIS

BRACHIORADIALIS Latin, brachial, relating to the arm; radius, staff, spoke of wheel. Part of the superficial group. The brachioradialis forms the lateral border of the cubital fossa. The muscle belly is prominent when working against resistance. Origin Upper two-thirds of the anterior aspect of lateral supracondylar ridge of humerus (i.e. lateral part of shaft of humerus, 5-7.5cm (2-3\") above elbow joint). Insertion Lower lateral end of radius, just above the styloid process. Action Flexes elbow joint. Assists in pronating and supinating forearm when these movements are resisted. Nerve RBasdiicalfunnercvteio, nCa5l, 6m. o v e m e n t Example: Turning a corkscrew. Indications Elbow pain. Pain in thumb (dorsum). Tennis elbow (lateral epicondylitis). Weakness in grip. Repetitive strain injury. Referred pain patterns Lateral epicondyle area 3-4cm patch with vague arm pain (radius border), localizing into strong pain dorsum of thumb. Differential diagnosis De Quervain's tenosynovitis. Osteoarthritis of thumb (trapezium). Also consider Biceps brachiii. Brachialis. Extensor carpi radialis longus, and brevis. Supinator. Extensor digitorum. Advice to patient Avoid long standing. Carrying (briefcases). Take regular breaks when typing. Use wrist supports. TCehcahnngiequgerisp on tennis raquet. Spray and stretch Dry needling Injections Trigger point release

WRIST EXTENSORS

WRIST EXTENSORS Latin, extensor, to extend; carpi, of the wrist; radius, staff, spoke of wheel; longus, long; brevis, short; ulnaris, of the elbow. Includes extensor carpi radialis longus and brevis, and extensor carpi ulnaris. Origin Common extensor tendon from lateral epicondyle of humerus (i.e. lower lateral end of humerus). Insertion Dorsal surface of metacarpal bones. Action Extends the wrist (extensor carpi radialis and brevis also abduct the wrist; extensor carpi ulnaris also adducts the wrist). Nerve Radialis longus and brevis: radial nerve, C5, 6, 7, 8. Extensor carpi ulnaris: deep radial (posterior interosseous) nerve, C5, 6, 7, 8. Basic functional movement Examples: Kneading dough. Typing. Cleaning windows. Indications Forearm, elbow, wrist and hand pain. Finger stiffness. Painful/weak grip. Tennis elbow. Pain on gripping and twisting, seen in musicians/athletes/long distance drivers. Loss of control (fine) on gripping activities. Referred pain patterns Extensor carpi radialis longus: strong 2-3cm zone over lateral epicondyle, diffusely radiating to dorsum of hand above thumb. Extensor carpi radialis brevis: strong zone of pain 3-5cm over dorsum of hand. Extensor carpi ulnaris: strong, localized, specific referral to dorsal ulnar surface of hand and bulk of wDirfifset.rential diagnosis Epicondylitis. C5-C6 radiculopathy. De Quervain's tenosynovitis. Articular dysfunction of wrist. Osteoarthritis. Carpal tunnel syndrome. Also consider Supinator. Brachioradialis. Extensor digitorum. Triceps brachii. Biceps brachii. Anconeus. Advice to patient Avoid 'over' gripping in sports. Take regular breaks/rests when gardening/driving. Explore occupational factors/ergonomics. Home stretch and exercises. Change grip width in golf/tennis. Use of wrist splints. Techniques Spray and stretch Dry needling Injections Trigger point release

EXTENSOR DIGITORUM

EXTENSOR DIGITORUM Latin, extensor, to extend; digit, finger. Part of the superficial group. Each tendon of extensor digitorum, over each metacarpophalangeal joint, forms a triangular membranous sheet called the extensor hood or extensor expansion, into which insert the lumbricales and interossei of the hand. Extensor digiti minimi and extensor indicis also insert into the extensor expansion. Origin Common extensor tendon from lateral epicondyle of humerus (i.e. lower lateral end of humerus). Insertion Dorsal surfaces of all the phalanges of the four fingers. Action Extends the fingers (metacarpophalangeal and interphalangeal joints). Assists abduction (divergence) of fingers away from the middle finger. Nerve Deep radial (posterior interosseous) nerve, C6, 7, 8. Basic functional movement Example: Letting go of objects held in the hand. Indications Finger, hand and wrist pain. Elbow pain. Stiffness and pain in fingers. Weakness in fingers (decreased grip). Tennis elbow. Pain on forceful gripping, often seen in professional musicians (esp. guitarists). Referred pain patterns Diffuse pain from forearm becoming more intense in the appropriate finger (proximal metacarpal). Pain in lateral epicondyle. Differential diagnosis Radiculopathy (cervical). Epicondylitis (tennis elbow). Osteoarthritis of fingers. De Quervain's tenosynovitis. Mechanical wrist pain (carpals). Also consider Brachioradialis. Supinator. Extensor carpi radialis longus. Extensor indicis. Advice to patient Home exercise programme. Self stretch. Avoid sustained gripping. Explore work posture/arrangement with reference to computer keyboards/mouse. Avoid habitual postures such as sleeping with hands folded under head/pillow. Techniques Spray and stretch Dry needling Injections Trigger point release

SUPINATOR

SUPINATOR Latin, supinus, lying on the back. Part of the deep group. Supinator is almost entirely concealed by the superficial muscles. Origin Lateral epicondyle of humerus. Radial collateral (lateral) ligament of elbow joint. Annular ligament of superior radio-ulnar joint. Supinator crest of ulna. Insertion Dorsal and lateral surfaces of upper third of radius. Action Supinates forearm (for which it is probably the main prime mover, with biceps brachii being an auxiliary). Nerve Deep radial nerve, C5, 6, (7). Basic functional movement Example: Turning a door handle or screwdriver. Indications Tennis elbow. Thumb joint pain. Elbow pain (when carrying and at rest). Pain turning door knobs. Localized pain on supination. Chronic use of walking stick. Pain on handshake. Referred pain patterns Localized 3-5cm strong zone of pain at lateral epicondyle and at web of thumb (dorsum). Differential diagnosis De Quervain's tenosynovitis. Lateral epicondylitis (tendino-osseous, musculo-tendinous, intramuscular). Radial head dysfunction. Also consider Common extensors. Biceps brachii. Triceps brachii (insertion). Anconeus. Brachialis. Palmaris longus. Brachioradialis. Extensor carpi radialis longus. Advice to patient Change tennis style (keep wrists dorsiflexed). Change grip size. Avoid prolonged gripping/carrying. Change walking stick side regularly. Use pressure bandage /strap. Use backpack. Techniques Spray and stretch Dry needling Injections Trigger point release

OPPONENS POLLICIS/ADDUCTOR POLLICIS

OPPONENS POLLICIS/ADDUCTOR POLLICIS Latin, opponens, opposing; pollicis, of the thumb; adduct, towards. Opponens pollicis is part of the thenar eminence, usually partly fused with flexor pollicis brevis and deep to abductor pollicis brevis. Origin Opponens pollicis: flexor retinaculum. Tubercle of trapezium. Adducor pollicis: oblique fibres: anterior surfaces of second and third metacarpals, capitate and trapezoid. Transverse fibres: palmar surface of third metacarpal bone. Insertion Opponens pollicis: entire length of radial border of first metacarpal. Adductor pollicis: ulna (medial) side of base of proximal phalanx of thumb. Action Opponens pollicis: opposes (i.e. abducts, then slightly medially rotates, followed by flexion and adduction) the thumb so that the pad of the thumb can be drawn into contact with the pads of the fingers. Adductor pollicis: adducts the thumb. Nerve Opponens pollicis: median nerve (C6, 7, 8, T l ) . Adductor pollicis: deep ulnar nerve, C8, Tl. Basic functional movement Example: Picking up small object between thumb and fingers (opponens pollicis). Gripping a jam jar lid to screw it on (adductor pollicis). Indications 'Weeder's thumb'. Thumb pain on activity. Difficulty on maintaining pincer movement. 'Texter's', and 'video gamer's' thumb. Pain on sewing, writing and opening jars. Loss of fine motor control in buttoning, sewing, writing and painting, etc. Referred pain patterns Opponens pollicis: palmar wrist pain at distal radial head and into palmar aspect of thumb. Adductor pollicis: dorsal and palmar surfaces of thumb localized around metacarpophalangeal joint and radiating to web of thumb and thenar eminence. Differential diagnosis De Quervain's tenosynovitis. Osteoarthritis of thumb (saddle joint). Rheumatoid arthritis. Carpal tunnel syndrome. 'Trigger thumb'. Discopathy of distal radio-ulnar joint. Carpal bones dysfunction. Mechanical dysfunction. Fracture. Subluxation. Also consider Abductor pollicis brevis. Flexor pollicis brevis. Flexor pollicis longus. Advice to patient Home stretching exercises. Take regular breaks. Ergonomic pens, etc. Use warmth. Techniques Spray and stretch Dry needling Injections Trigger point release

SMALL HAND MUSCLES

SMALL HAND MUSCLES Latin, dorsal, back; interosseus, between bones; lumbrical, earthworm; abductor, away from; digit, finger; minimi, smallest. Comprising: dorsal interossei, lumbricales and abductor digiti minimi. The four dorsal interossei are about twice the size of the palmar interossei. The lumbricales are composed of small cylindrical muscles, one for each finger. Abductor digiti minimi is the most superficial muscle of the hypothenar eminence. Origin Dorsal interossei: by two heads, each from adjacent sides of metacarpals. Lumbricales: tendons of flexor digitorum profundus in the palm. Abductor digiti minimi: pisiform bone. Tendon of flexor carpi ulnaris. Insertion Dorsal interossei: into the extensor expansion and to base of proximal phalanx. Lumbricales: lateral (radial) side of corresponding tendon of extensor digitorum, on the dorsum of the respective digits. Abductor digiti minimi: Ulna (medial) side of base of proximal phalanx of little finger. Action Dorsal interossei: abduct fingers away from middle finger. Assist in flexion of fingers at metacarpophalangeal joints. Lumbricales: extend the interphalangeal joints and simultaneously flex the metacarpophalangeal joints of the fingers. Abductor digiti minimi: abducts the little finger. Nerve Dorsal interossei: ulnar nerve, C8, Tl. Lumbricales: lateral; median nerve, C(6), 7, 8, T l ; medial; ulnar nerve, C(7), 8, T l . Abductor digiti minimi: ulnar nerve, C(7), 8, T l . Basic functional movement Example: Spreading fingers. Cupping your hand. Holding a large ball. Indications Finger pain and stiffness. Pain when pinching/gripping, associated with Heberdan's node(s), e.g. in professional musicians (esp. pianists). 'Arthritic' finger pain, also seen in artists/sculptors. Referred pain patterns First dorsal interossei: strong finger pain in dorsum of index finger (lateral half), with vague pain on palmar surface and dorsum of hand. Other dorsal interossei: referred pain to the specific associated finger. Lumbricales: pattern is similar to interossei. Abductor digiti minimi: pain in dorsum of little finger. Differential diagnosis Cervical radiculopathy. Ulnar neuritis. Thoracic outlet syndrome. Digital nerve entrapment. Articular dysfunction. Also consider Intrinsic thumb muscles. Scalenes. Latissimus dorsi. Long finger flexors and / or extensors. Pectoralis major. Lateral and /or medial head of triceps brachii. Advice to patient Stretching and exercising. Examine work postures/ergonomics. Explore sporting activities (e.g. grip in golf). Use of ergonomic pens/cutlery. Techniques Spray and stretch Dry needling Injections Trigger point release



GLUTEUS MAXIMUS

GLUTEUS MAXIMUS Greek, gloutos, buttock; maximus, biggest. The gluteus maximus is the most coarsely fibred and heaviest muscle in the body, forming the bulk of the buttock. Origin Outer surface of ilium behind posterior gluteal line and portion of bone superior and posterior to it. Adjacent posterior surface of sacrum and coccyx. Sacrotuberous ligament. Aponeurosis of erector spinae. Insertion Deep fibres of distal portion: gluteal tuberosity of femur. Remaining fibres: iliotibial tract of fascia lata. Action Upper fibres: laterally rotate hip joint. May assist in abduction of hip joint. Lower fibres: extend and laterally rotate hip joint (forceful extension as in running or rising from sitting). Extend trunk. Assists in adduction of hip joint. Through its insertion into the iliotibial tract, helps to stabilize the knee in extension. Nerve Inferior gluteal nerve, L5, SI, 2. Basic functional movement Examples: Walking upstairs. Rising from sitting. Indications Pain on sitting. Pain walking (up hill). Pain on flexion. Buttock pain when swimming. Buttock pain after a fall or trip. Night pain. Restricted hip/thigh flexion. Listing gait. Cramping in cold. Referred pain patterns Three to four strong zones of pain in the buttock, with intercommunicating diffuse pain, occasionally just below (5-8cm) gluteal fold. Differential diagnosis Coccydynia. Pelvic inflammatory disease. Lower lumbar discopathy. Sacroiliitis. Bursitis (ischial tuberosity/trochanteric). Mechanical low back pain. Also consider Other gluteal muscles. Quadratus lumborum. Pubococcygeus. Hamstring muscles (attachment trigger points). Advice to patient Warmth and stretching. Gait and posture analysis. Pillow between knees when sleeping. Stretching programme. Swimming (not crawl). Techniques Spray and stretch Dry needling Injections Trigger point release

TENSOR FASCIAE LATAE

TENSOR FASCIAE LATAE Latin, tensor, stretcher, puller; fascia(e), band(s); latae, broad. This muscle lies anterior to gluteus maximus, on the lateral side of the hip. Origin Anterior part of outer lip of iliac crest, and outer surface of anterior superior iliac spine. Insertion Joins iliotibial tract just below level of greater trochanter. Action Flexes, abducts and medially rotates the hip joint. Tenses the fascia lata, thus stabilizing the knee. Redirects the rotational forces produced by gluteus maximus. Nerve Superior gluteal nerve, L4, 5, SI. Basic functional movement Example: Walking. Indications Hip and knee pain (lateral). Pain on side lying. Pain on fast walking. Hip replacement rehabilitation. Fracture of neck of femur rehabilitation. Referred pain patterns Strong elliptical zone of pain from greater trochanter inferolaterally towards fibula. Differential diagnosis Trochanteric bursitis. Osteoarthritic hip. Sacroiliitis. Lumbar spondylosis. Also consider Gluteus medius. Gluteus minimus. Vastus lateralis. Rectus femoris. Sartorius. Quadratus lumborum. Advice to patient TAevcohidniinqguepsrolonged positions (flexion). Avoid habitual postures (cross-legged, or standing on one leg). Pillow between knees at night. Running style, gait and posture assessment. Warm up. Stretch regularly. Spray and stretch Dry needling Injections Trigger point release

GLUTEUS MEDIUS

GLUTEUS MEDIUS Greek, gloutos, buttock; medius, middle. This muscle is mostly deep to and therefore obscured by gluteus maximus, but appears on the surface between gluteus maximus and tensor fasciae latae. During walking, this muscle, with gluteus minimus, prevents the pelvis from dropping towards the non weight-bearing leg. Origin Outer surface of ilium inferior to iliac crest, between the posterior gluteal line and the anterior gluteal line. Insertion Oblique ridge on lateral surface of greater trochanter of femur. Action Abducts the hip joint. Anterior fibres medially rotate and may assist in flexion of the hip joint. Posterior fibres slightly laterally rotate the hip joint. Nerve Superior gluteal nerve, L4, 5, S I . Basic functional movement Example: Stepping sideways over an object such as a low fence. Indications Pain and tenderness in low back and buttocks. Night pain. Pain side lying. Post hip or spinal surgery. Sitting on wallet. Referred pain patterns Low back, medial buttock, sacral and lateral hip radiating somewhat into the upper thigh. Differential diagnosis Radiculopathy (lumbosacral). Sacroiliitis. Hip joint dysfunction. Coccydynia. Greater tuberosity bursitis. Mechanical low back pain. Intermittent claudication. Also consider Quadratus lumborum. Other gluteal muscles. Pubococcygeus. Tensor fasciae latae. IT band. Piriformis. Lumbar erector spinae. Advice to patient Gait and posture analysis. Pillow between knees. Habitual postures. Stretching techniques. Techniques Spray and stretch Dry needling Injections Trigger point release

GLUTEUS MINIMUS